Strengthening Surgical Foundations: The K.N.O.T. (Keep No Operation Tangled) Campaign For Surgical Skill-building Among Medical Students In The Low-resource Settings

Strengthening Surgical Foundations: The K.N.O.T. (Keep No Operation Tangled) Campaign For Surgical Skill-building Among Medical Students In The Low-resource Settings

Ashmita Khatri , Aashutosh Ghimire, Bishow Bekhyat Karki, Bikram Thapa, Prarthana Subedi, Mahmoud Loubani
KIST Medical College and Teaching Hospital, Lalitpur, Nepal; Manipal College of medical sciences, Pokhara, Nepal; Leeds Teaching Hospital NHS Trust, Leeds, United Kingdom; Oxford university clinical research unit , National academy of medical sciences, Kathmandu, Nepal; Hull University Teaching Hospitals NHS Trust, Hull, United Kingdom

Introduction: The K.N.O.T. Campaign, under Global Surgery Simulation Network(GSSN), targeted knot-tying skills among medical students. In low-resource settings, surgical training faces systemic challenges, including insufficient faculty, infrastructure, reliance on apprenticeship models, which compromise skill standardization. Peer-assisted learning demonstrated efficacy in surgical skill acquisition, particularly where resources are constrained. The K.N.O.T. Campaign introduced peer teaching model with train-the-trainer approach aimed at empowering students to improve knot-tying and gloving skills.

Aim: To evaluate the effectiveness of KNOT Campaign’s peer teaching approach in improving surgical knot-tying skills among medical students in Nepal and to assess scalability of train-the-trainer approach in low-resource settings.

Methodology: A quantitative study was conducted involving medical students from 17 medical colleges in Nepal through two-phase intervention. In Phase 1, students received virtual knot-tying training through live demonstrations by certified Intercollegiate Basic Surgical Skills faculty from the UK using cup, thread, KNOT Box and replicated it using train-the-trainer model. In Phase 2, peer-to-peer teaching expanded beyond GSSN. Surveys were shared online and analysed using SPSS.

Results: 825 students were engaged, with over 600 cumulative hours of hands-on practice. 87.2% had no prior exposure to knot-tying. Confidence improved in all techniques; Reef Knot by +2.14, Single-Handed (+2.17), Double-Handed (+2.09), Tying at Depth (+2.23),Instrument Knot-tying (+2.17); all p<0.001. Confidence in gloving increased by +0.73 (p<0.001). 65.8% demonstrated high accuracy. 59.5% trained peers. 79.4% found peer learning very/extremely helpful.

Conclusion: K.N.O.T. Campaign elevated knot-tying skills using train-the-trainer and peer teaching providing scalable model for basic surgical training in low-resource settings.

Keywords: Surgical Skill, Keep No Operation Tangled, Surgical Training